Journal of Patient-Centered Journal of Patient-Centered
Research and Reviews Research and Reviews
Volume 7
Issue 4
-- Women and Cancer
Article 1
10-23-2020
Action Items for Breast Cancer Awareness Month Action Items for Breast Cancer Awareness Month
Deanna J. Attai
Follow this and additional works at: https://aah.org/jpcrr
Part of the Community Health and Preventive Medicine Commons, Health Services Research
Commons, Neoplasms Commons, Oncology Commons, Public Health Education and Promotion
Commons, Surgery Commons, Translational Medical Research Commons, and the Women's Health
Commons
Recommended Citation Recommended Citation
Attai DJ. Action items for Breast Cancer Awareness Month. J Patient Cent Res Rev. 2020;7:291-4. doi:
10.17294/2330-0698.1801
Published quarterly by Midwest-based health system Advocate Aurora Health and indexed in PubMed Central, the
Journal of Patient-Centered Research and Reviews (JPCRR) is an open access, peer-reviewed medical journal
focused on disseminating scholarly works devoted to improving patient-centered care practices, health outcomes,
and the patient experience.
www.aah.org/jpcrr 291
FROM THE EDITOR
Action Items for Breast Cancer Awareness Month
October is Breast Cancer Awareness Month (BCAM) in
many countries, and it’s hard to miss it. Pink merchandise
oods the stores, all types of products are labeled with
pink ribbons, and countless stories are told of women
who have “beat” breast cancer. Often, the messaging
is focused on early detection and the importance of
screening mammograms.
This special issue of the Journal of Patient-Centered
Research and Reviews is dedicated to the theme “Women
and Cancer.” In addition to containing original research
on uterine cancer, hysterectomy, and pain relief during
labor,
1-3
several articles published within this issue
pertain to predicting treatment outcomes, improving
quality of life, and gleaning the patient perspective of
those aected by breast cancer.
4-8
These impactful studies
are the kind that demand further support, both in terms of
patient participation and research funding, and it’s time
for awareness campaigns to drive the public toward such
new and promising goals.
Herein, we briey describe the origination of marketing
campaigns aimed at increasing breast cancer awareness
and how these campaigns could be updated to avoid
losing relevance to a present-day public already educated
on the importance of screening.
History of the Pink Ribbon
The pink ribbon that has adorned everything from National
Football League player uniforms to bags of pet food actually
started o as a peach-colored ribbon. The message that
Charlotte Haley wanted to send in 1992 was one of lack of
research funding for cancer prevention. When she declined
to allow her ribbon to be used for a magazine marketing
campaign, a pink ribbon was
used instead.
9,10
Since that
time, breast cancer advocacy
organizations are often
distinguished by pink logos
and use the ribbon in their
educational and marketing
materials. Many wear pink
to signify their struggles with
the disease or to show support
for a loved one who has been
treated for breast cancer.
However, the pink ribbons are not always appreciated.
Some people with breast cancer do not feel comfortable
being “branded” or identied by their medical condition,
and many patients do not identify with the term
“survivor,”
11
which is often used in BCAM campaigns.
Men and the impact of male breast cancer are often left
out of BCAM messaging. In addition, concerns have been
raised regarding “pinkwashing,” when a pink ribbon and
inspiring slogan are placed on a product with a message
of awareness, even though no proceeds from the sale of
the product actually go toward breast cancer education,
detection, or research.
12
The reality of breast cancer is that the patient experience
does not always t neatly into a positive or inspirational
marketing campaign. Eorts to raise awareness of breast
cancer risk factors, benets of screening, and treatment
options remain necessary. However, there are important
aspects of breast cancer not being addressed at many
of the attention-grabbing pink ribbon events, including
metastatic breast cancer, male breast cancer, and racial
and ethnic disparities related to diagnosis, treatment,
and outcomes. Thus the question is raised: Is spreading
awareness enough, and do existing advocacy campaigns
accurately reect the many faces of breast cancer?
Metastatic Breast Cancer
The traditional messaging that “early detection saves
lives” does not always hold true — early detection is
Corresponding author: Deanna J. Attai, MD,
UCLA Health Burbank Breast Care, 191 S. Buena Vista,
#415, Burbank, CA 91505 ([email protected])
From the Editor
Deanna J. Attai, MD | Issue Editor (Women and Cancer)
Department of Surgery, David Geen School of Medicine at UCLA, Los Angeles, CA
292 JPCRR • Volume 7, Issue 4 • Fall 2020
From the Editor
important, but it is not the only factor that impacts survival.
Metastatic breast cancer occurs when the original tumor
has spread beyond the breast and regional lymph nodes,
most commonly to the lungs, liver, bone, and brain.
13
It
is estimated that there are approximately 150,000 women
in the United States currently living with metastatic
breast cancer. However, U.S. registries do not routinely
collect or report recurrence data, so more precise gures
are not available.
14,15
Metastases are more likely to occur
in the setting of higher stage at diagnosis or aggressive
tumor biology but can occur even in those diagnosed
with early stage, slower growing tumors, including after
a long disease-free interval. Approximately 6% of all
newly diagnosed breast cancers are de novo metastatic,
meaning they are metastatic at the time of diagnosis.
16
The
American Cancer Society estimates that approximately
41,000 women and 500 men in the United States will die
this year due to breast cancer,
16
with most of these deaths
caused by metastatic breast cancer. Death from breast
cancer certainly does not t into the “survivor” narrative,
and patients with metastatic breast cancer are often left
out of awareness campaigns. In 2009, the U.S. Congress
did designate October 13 as National Metastatic Breast
Cancer Awareness Day.
17
Metastatic breast cancer can develop in those who
have been adherent to recommended screening and
therapy, essentially having “done everything right.”
While treatments continue to advance and many with
metastatic disease are experiencing improved survival
rates compared with years past, there is no cure. The
fact is, we do not always understand why some patients
develop metastatic cancer and some do not, or why some
metastatic cancers progress despite modern therapy and
some are controlled. This knowledge gap could be closed
sooner if all breast cancer advocacy groups devoted more
of their time, platform, and resources toward metastatic
research eorts. As one advocacy organization asserts in
its tagline, these patients are “dying for a cure.”
18
Male Breast Cancer
Male breast cancer accounts for approximately 1% of
all breast cancers. This small percentage presents a
challenge, as the relative infrequency of breast cancer
occurring in men contributes to limited awareness and
lack of inclusion in many clinical trials. Men are more
likely to be diagnosed at later stages, and their outcomes
are poorer compared with women diagnosed at the same
stage. Treatment for male breast cancer usually follows
established protocols for breast cancer treatment in
women, despite lack of evidence in some situations.
19,20
Despite this disease burden, men are not commonly
featured in awareness campaigns, missing an opportunity
to educate the public about presenting signs and
symptoms, treatment options, and the association of male
breast cancer with pathogenic genetic mutations (eg,
BRCA mutations). This is slowly changing, in part due to
media attention when a male celebrity is diagnosed
21
and
the tireless work of patient advocacy groups. The Male
Breast Cancer Coalition series titled “Men Have Breasts
Too” features patient stories from men diagnosed with
breast cancer,
22
which can serve as a source of education
and support for men diagnosed with what is typically
considered a “female” disease.
Inclusion of men in clinical trials is an important and
essential step to help determine the best treatment
approach for male breast cancer. The U.S. Food and Drug
Administration (FDA) has recently recommended that
men be included in clinical trials evaluating medications
for the treatment of breast cancer, specically noting
that the “FDA does not intend to consider low expected
accrual rates of male patients with breast cancer to be a
sucient scientic rationale for excluding them from a
clinical trial.”
23
An ongoing international multicenter
collaboration should provide important insights into the
biologic dierences between breast cancer in men and
women, as well as draw attention to the unique physical
and psychological eects experienced by men diagnosed
with and treated for breast cancer.
19,24
Men must be included in advocacy and awareness
campaigns with a focus on presenting symptoms,
treatment options, the role of family history and genetic
testing, and the unique supportive care needs of men.
Disparities
Not all patient populations have beneted from
improvements in cancer screening, treatment, and
outcomes. Disparities exist and may be related to race
or ethnicity, socioeconomic status, sexual orientation,
gender identity, and other factors.
25,26
Costs of care,
including nonmedical costs such as transportation, may
disproportionately aect certain patient populations.
27,28
Importantly, not all disparities can be adequately
explained by imbalanced societal structures, health care
barriers and biases, or simple awareness. Breast cancer
is less common in Black women compared with White
women, but Black women have poorer outcomes, in part
due to later stage and younger age at diagnosis, as well
as higher likelihood of diagnosis with the triple-negative
subtype. Biological dierences in breast cancers in Black
compared with White women have been identied,
although more research is needed to determine the impact
of biological versus socioeconomic factors associated
with delays in diagnosis and higher mortality rates.
29-31
www.aah.org/jpcrr 293From the Editor
While there are a growing number of advocacy groups
specically focused on minority patient populations and
their unique needs, large national advocacy organizations
should take the lead to ensure that their awareness
campaigns and support programs also address these
issues. The American Society of Clinical Oncology has
recently updated its policy statement on cancer disparities
and health equity with specic recommendations to
promote health equity by focusing on access to high-
quality care, improving clinical research, and addressing
structural barriers.
25,26
Clinical Trials and Research Funding
A common theme in discussing those traditionally
marginalized by BCAM campaigns is the importance of
research and clinical trials. However, less than 10% of
all patients with cancer in the United States are enrolled
in a clinical trial as part of their treatment.
32
There are
many barriers to accrual: lack of understanding of the
importance and potential benets of clinical trials;
lack of an available trial for a specic cancer type or
stage; narrow eligibility criteria; treatment protocols
requiring care at a centralized facility that may not be
geographically convenient; transportation and other
costs; and biases, unconscious or otherwise, on the part
of medical teams.
32-35
Despite eorts to include diverse
and representative populations in available trials, these
barriers often disproportionately aect those of lower
socioeconomic status as well as racial and ethnic minority
populations, therefore trial results may not equally apply
to all aected with breast cancer.
36
Another challenge is that national research funding is
subject to changes in federal budget and administration
priorities.
37,38
Charlotte Haley’s original vision for the
peach ribbon was to call attention to lack of research
funding, and it has become more important than ever that
the general public be aware that pink ribbons and labels
do not equal progress. Awareness campaigns that do not
emphasize the importance of research will not contribute
to meaningful progress.
Pushing Forward
There is no doubt that spreading breast cancer awareness
is still necessary. But awareness that is not partnered with
action will not result in progress. Awareness campaigns
need to accurately represent all of the faces of breast
cancer, address barriers and promote equitable access to
care, and emphasize the importance of research. Only
then do we have any hope of making a real impact toward
ensuring timely diagnosis and care, improving quality of
life, and reducing the number of women and men who
die from this disease every year.
References
1. Riggs MJ, Cox Bauer CM, Miller CR, Aden JK, Kamelle SA.
Validation of an endometrial tumor diameter model for risk
assessment when lymph node mapping fails. J Patient Cent
Res Rev. 2020;7:323-8.
2. Sangha R, Bossick A, Su WTK, Coleman C, Chavali N,
Wegienka G. A prospective study of patterns of regret in the year
after hysterectomy. J Patient Cent Res Rev. 2020;7:329-36.
3. Horter DA, Heslin K, Forgie M, Malloy E, Kram JJ. Dancing
during labor: Are women down to boogie? J Patient Cent Res
Rev. 2020;7:349-54.
4. Storey S, Cohee A, Von Ah D, et al. Presence and distress
of chemotherapy-induced peripheral neuropathy symptoms
in upper extremities of younger and older breast cancer
survivors. J Patient Cent Res Rev. 2020;7:295-303.
5. Katz MS, Staley AC, Attai DJ. A history of #BCSM
and insights for patient-centered online interaction and
engagement. J Patient Cent Res Rev. 2020;7:304-12.
6. Cairo J, Williams L, Bray L, Goetzke K, Perez AC. Evaluation
of a mobile health intervention to improve wellness
outcomes for breast cancer survivors. J Patient Cent Res Rev.
2020;7:313-22.
7. Reddy S, Saxon M, Patel N, et al. Discordance in perceptions
of barriers to breast cancer treatment between Hispanic women
and their providers. J Patient Cent Res Rev. 2020;7:337-42.
8. Gregory WD, Christie SM, Shell J, Nahhas GJ, Singh M,
Mikkelson W. Cole relaxation frequency as a prognostic
parameter for breast cancer. J Patient Cent Res Rev.
2020;7:343-8.
9. Hendrix K. Peach Corps: Activism: Breast cancer has
aicted her grandmother, sister and daughter, so Charlotte
Haley is urging people to wear ribbons to ‘wake up’ America.
Los Angeles Times. Published August 20, 1992; accessed
September 6, 2020. https://www.latimes.com/archives/la-
xpm-1992-08-20-vw-6473-story.html
10. Fernandez SM; thinkbeforeyoupink.org. History of the pink
ribbon. Pretty in pink. Accessed August 25, 2020. https://
thinkbeforeyoupink.org/resources/history-of-the-pink-ribbon/
11. Berry LL, Davis SW, Godfrey Flynn A, Landercasper
J, Deming KA. Is it time to reconsider the term “cancer
survivor”? J Psychosoc Oncol. 2019;37:413-26. Crossref
12. thinkbeforeyoupink.org. 4 questions before you buy pink.
Accessed August 25, 2020. https://thinkbeforeyoupink.org/
resources/before-you-buy/
13. Cancer.Net
™
. Breast cancer – metastatic: introduction.
Page content approved April 2019; accessed September 5,
2020. https://www.cancer.net/cancer-types/breast-cancer-
metastatic/introduction
14. Waks AG, Winer EP. Breast cancer treatment: a review.
JAMA. 2019;321:288-300. Crossref
15. Mariotto AB, Etzioni R, Hurlbert M, Penberthy L, Mayer M.
Estimation of the number of women living with metastatic
breast cancer in the United States. Cancer Epidemiol
Biomarkers Prev. 2017;26:809-15. Crossref
16. American Cancer Society. Breast Cancer Facts & Figures
2019-2020. American Cancer Society, Inc.; 2019. Accessed
September 5, 2020. Available at: https://www.cancer.org/
content/dam/cancer-org/research/cancer-facts-and-statistics/
breast-cancer-facts-and-figures/breast-cancer-facts-and-
gures-2019-2020.pdf
294 JPCRR • Volume 7, Issue 4 • Fall 2020
17. Metastatic Breast Cancer Network. History of Metastatic
Breast Cancer Day – October 13. Accessed September 5,
2020. http://mbcn.org/history-of-metastatic-breast-cancer-
day-october-13/
18. METUP.ORG. Home page. Accessed September 6, 2020.
http://metup.org/
19. Giordano SH. Breast cancer in men. N Engl J Med.
2018;378:2311-20. Crossref
20. Hassett MJ, Somereld MR, Baker ER, et al. Management
of male breast cancer: ASCO guideline. J Clin Oncol.
2020;38:1849-63. Crossref
21. Taylor DB. Beyoncé’s father, Mathew Knowles, on his breast
cancer diagnosis. The New York Times. Published October
3, 2019; accessed August 25, 2020. https://www.nytimes.
com/2019/10/03/us/mathew-knowles-breast-cancer.html
22. The Male Breast Cancer Coalition. Men have breasts too.
Accessed August 25, 2020. https://malebreastcancercoalition.
org/men-have-breasts-too/
23. U.S. Food and Drug Administration. Male breast cancer:
developing drugs for treatment. Guidance for industry.
Accessed August 25, 2020. https://www.fda.gov/regulatory-
information/search-fda-guidance-documents/male-breast-
cancer-developing-drugs-treatment
24. Cardoso F, Bartlett JMS, Slaets L, et al. Characterization of
male breast cancer: results of the EORTC 10085/TBCRC/
BIG/NABCG International Male Breast Cancer Program. Ann
Oncol. 2018;29:405-17. Crossref
25. Patel MI, Lopez AM, Blackstock W, et al. Cancer disparities
and health equity: a policy statement from the American
Society of Clinical Oncology. J Clin Oncol. 2020;38:3439-48.
Crossref
26. Pierce LJ. A time to dig deeper and take meaningful action.
J Clin Oncol. 2020;38:3361-2. Crossref
27. Lee A, Shah K, Chino F. Assessment of parking fees at
National Cancer Institute-designated cancer treatment centers.
JAMA Oncol. 2020;6:1295-7. Crossref
28. Chino F, Peppercorn JM, Rushing C, et al. Out-of-pocket
costs, nancial distress, and underinsurance in cancer care.
JAMA Oncol. 2017:3:1582-4. Crossref
29. Newman LA. Breast cancer disparities: socioeconomic factors
versus biology. Ann Surg Oncol. 2017;24:2869-75. Crossref
30. Scott LC, Mobley LR, Kuo TM, Il’yasova D. Update on
triple-negative breast cancer disparities for the United
States: a population-based study from the United States
Cancer Statistics database, 2010 through 2014. Cancer.
2019;125:3412-7. Crossref
31. Singh M, Konduri SD, Bobustuc GC, Kassam AB, Rovin
RA. Racial disparity among women diagnosed with invasive
breast cancer in a large integrated health system. J Patient
Cent Res Rev. 2018;5:218-28. Crossref
32. Unger JM, Vaidya R, Hershman DL, Minasian LM, Fleury
ME. Systematic review and meta-analysis of the magnitude of
structural, clinical, and physician and patient barriers to cancer
clinical trial participation. J Natl Cancer Inst. 2019;111:245-55.
Crossref
33. Cancer Action Network; American Cancer Society. Barriers
to patient enrollment in therapeutic clinical trials for cancer.
Posted April 11, 2018; accessed August 25, 2020. https://
www.ghtcancer.org/policy-resources/clinical-trial-barriers
34. Chino F, Zafar SY. Financial toxicity and equitable access to
clinical trials. Am Soc Clin Oncol Educ Book. 2019;39:11-8.
Crossref
35. Winkeld KM, Philips JK, Joe S, Halpern MT, Wollins DS,
Moy B. Addressing nancial barriers to patient participation
in clinical trials: ASCO policy statement. J Clin Oncol.
2018;36:3331-9. Crossref
36. Freedman RA, Ruddy KJ. Who are the patients in our clinical
trials for cancer? J Clin Oncol. 2019;37:1519-23. Crossref
37. American Society of Clinical Oncology. Research funding
by the National Cancer Institute: from pipeline to patient.
Accessed September 5, 2020. https://www.asco.org/sites/
new-www.asco.org/les/content-les/advocacy-and-policy/
images/ASCO-Cancer-Research-Pipeline-Infographic.pdf
38. ASCO in Action. Cancer community and other stakeholders
urge $3 billion NIH funding increase for FY2021: take action.
Posted February 18, 2020; accessed September 5, 2020. https://
www.asco.org/practice-policy/policy-issues-statements/asco-
in-action/cancer-community-and-other-stakeholders-urge
© 2020 Advocate Aurora Health, Inc.
From the Editor